ANA s Policy Leadership: Advancing Usability/Safety with Health Information Technology (HIT)

Transcription

1 ANA s Policy Leadership: Advancing Usability/Safety with Health Information Technology (HIT) Maureen Dailey, PhD, RN, CWOCN Senior Policy Advisor, Department of Health Policy (HP)

2 ANA s Multi-pronged HIT Safety/Usability Policy Advocacy Advocacy via Office of the National Coordinator (ONC) for Health Information Technology (HIT) ANA/ONC Leadership Meetings Kelly Cochran, Policy Advisor - ANA s HIT policy lead, Department HP (Kelly.Cochran@ana,org) Kelly/I Cross Cover Intersection between Quality/Safety-HIT Increased Nursing Representation at ONC & ANA/ONC Collaboration Committees, Workgroups, and Meetings ANA-convened ANA/ONC Nurses Group ANA-convened ONC Nurse Appointee Group ANA Government Affairs (GOVA) and HP Congressional Advocacy (e.g., Senate HELP Committee) Advocacy with National Stakeholder Groups, Nursing and Non-nursing ANA Position Statements and Policy Briefs -

3 Quality Policy Portfolio ANA Quality Advocacy Across the National Quality Enterprise: Focus - Three National Quality Strategy (NQS) Priorities: Safety, Care Coordination, and Pt/Family- Centered Care Engagement Nursing Sensitive Measures Pay for Reporting and Quality Programs: Centers for Medicare and Medicaid Services (CMS) measure development contracts, emeasure Kaizen meetings, Technical Expert Panels (TEP) National Quality Forum (NQF) - Measure endorsement, prioritization, gap-filling Center for Medicare and Medicaid Innovation (CMMI) Projects Quality Improvement Partnership for Patients (PfP) Goals - Hospital acquired condition (40%) and 30 day readmission (20%) reduction ANA s CAUTI Prevention Tool Transforming Clinical Practice Initiative (TCPI) Goal to improve ambulatory care outcomes Agency for Healthcare Research and Quality (AHRQ) Improved Quality/Reduce Disparities Patient Centered Outcomes Research Institute (PCORI) Funding and Nursing Input (e.g. Roundtables) ANA-convened Nursing Alliance for Quality Care (NAQC)

4 Quality/HIT Policy Intersection NQS Tri-part goals: Better Care/Healthier People/Communities/More Affordable Care HIT is one of nine levers to advance the goals Collaborate/Integrate across internal ANA departments Integrate with ANA s national safety campaign (e.g., 2016 Culture of Safety) Nurses highest number (3.4 million versus 900K physicians) of HIT users EHR pain - > 500 clicks for nurses to do initial assessments (Sengstack, 2015)

5 ANA Joint Advocacy/Collaboration with Nursing/Non-Nursing Groups ANA s President Cipriano and CEO Weston Presentations Ongoing Advocacy with Key Nursing Groups: Alliance for Nursing Informatics (ANI) Policy comments and joint nominations collaboration AMIA Nursing Informatics Workgroup HIMSS Committees (e.g., Interprofessional Usability WG - and Nursing Informatics Committee American Nursing Informatics Association (ANIA) (e.g., Nursing Big Data/Analytics 2015 Conference Proceedings big-data-science-conference/index.htm ) Care coordination and Nursing Policy Advocacy Committees Interprofessional groups (e.g., National Institute of Standards and Technology (NIST) has released a guide aimed at making electronic health records more usable and thus safer,

6 Nursing Big Data: Care Coordination Project Purpose Identify nursing implications related to big data associated with care coordination. Rationale: No common measure has been developed in order to define the aspects of patients who may receive the most benefit from care coordination, leading to the most potential financial benefit, for the organizations providing care coordination services. Proposed Key Tasks Map the most common care coordination processes. Document the current state of care coordination and then begin to deconstruct the current state, breaking it down into segments or components to study further. Develop information model for the most important variables related to patients who will benefit most. Determine a strategy to identify from big data those who will most benefit from care coordination. Identify key patient characteristics from data elements in the EHR big data indicating the patients who will receive the most value Consider building off the HL7-reviewed care plan model for nursing value to show the interventions and outcomes associated with nursing care coordination work. Proposed Deliverables White paper discussing common care coordination processes. Begin the development of standardized processes across the continuum of care. Create a method to identify patients who will receive the most value from care coordination.

7 Nursing Big Data: HIT Policy Advocacy Project Purpose Engage all nurses in health IT policy efforts; To provide nurses with the education, tools and resources to equip them as knowledgeable advocates for policy efforts that are important to nursing. Proposed Key Tasks Identify existing and develop or modify relevant health IT policy-related educational tools and resources; make them available in a resource library for nurses. Include items such as: How to give testimony; How to write a blog What is health IT policy? Why is it important to nurses? Success stories, best practice examples, storyboards Contact information and listing of relevant individuals, groups and organizations. Key talking points/recommendations/position statements Student projects Example testimony, blogs, comments Newsletters, blogs and websites Webinars Describe how to contact elected officials, including visits, calls, , website communication, and the value of establishing an ongoing relationship with elected official staffers.

8 Key Nursing HIT Safety/Usability Advocacy in ONC Usability-Safety/Interoperability/Measurement Work Policy and Standards Committees Workgroups (WG) Newer Structure Topic-focused Task Forces Invitational Meetings (e.g., April, 2015 Care Plan Listening Session) Five nurse attendees Nurse presented regarding the HL7-reviewed standards for care plan ANA Regulatory Team: Comments to ONC led by Kelly - ANA s Comments Page - Advocacy/Federal/AGENCIES/ANA-Advises-Federal-Agencies Testimony - Expert Nursing Testimony (e.g., Use cases) Spread of Tools/Toolkits (e.g., ONS Safer Guides

9 Additional Key Safety/Usability Policy Advocacy Westhealth Interoperability between Medical Devices - Report/Meeting Links July, 2015 Pew Designing EHR Usability Recommended follow-up Develop a HIT Safety Standards Association for the Advancement for Medical Instrumentation (AAMI) Standards Link: Standards to apply to health service provider organizations and vendors that develop, implement, or use HIT software and systems NQF HIT Safety Framework/Measures Steering Committee

10 Nursing Presentation at PEW s Safety/Usability Conference ANA Advocacy Increases Nursing Representation and Supports Common Talking Points Ensures alignment with ANA/AAN seminal documents (e.g., care coordination) and HIT policy documents and comments Nursing Presentation - Nancy Staggers presented three pain points for nursing from patient-centered context: Documentation Care Coordination Medication management Links to Pew s Conference, Designing EHR Usability Presentations: Ayse Gurses Nancy Staggers Matt Weinger Andrew Gettinger

11 AAMI Safety Framework/Principles Invitational AAMI Conference/Meeting - Health IT Safety Framework/Principles AAMI HIT Safety Task Forces 1/2016 Two draft reports: 1) Application of Quality Management Principles to Health IT, and 2) Risk Management Practices for Health IT Learn more at: UghW0A.dpuf Multiple Workgroups (WG) and Higher-level Health IT Safety Committee Six nurse appointees

12 Current Related Nursing Work by ANA Members Nancy Staggers co-leads the HIMSS Usability WG Building on Nursing Usability Tiger Team report (2009) - Initial survey completed on nurse-focused usability (2015), white paper pending (1 st in a series) Publication Staggers et.al., (2015). Nursing-Centric Technology and Usability A Call to Action, Comput Inform Nurs.,33(8): Texas Tech state-wide usability survey/research: Dr. Susan McBride, PhD, RN BC, CPHIMS, FAAN Principle Investigator, Committee member Professor and Program Director Masters and Post Masters Nursing Informatics Texas Tech University Health Sciences Center, School of Nursing

13 Maureen Dailey, PhD, RN, CWOCN Prepare for Nominations: ANA leadership training opportunities - Send Bio/CV for Nominations - Yvonne Humes (Yvonne.Humes@ana.org) My contact: Maureen.Dailey@ana.org

14 Results and Modeling of the Texas Statewide Study on Nurse s Experience Using their Electronic Health Records Susan McBride, PhD, RN-BC, CPHIMS, FAAN

15 TNA/TONE Health IT Committee Charge: Determine implications of health care informatics for nursing practice and education in Texas Include nationally-based Technology Informatics Guiding Education Reform (TIGER) initiative Vision: To enable nurses and interprofessional colleagues to use informatics and emerging technologies to make healthcare safer, more effective, efficient, patientcentered, timely and equitable by interweaving evidence and technology seamlessly into practice, education and research fostering a learning healthcare system. TNA = Texas Nurses Association TONE = Texas Organization of Nurse Executives 1 5

16 Why Does HIT Matter Deep in the Heart of Texas? Benchmar k Reports on Progress Environmental Forces: Health Care Reform/ARRA Advanced Practice Nurse Roles EHR Incentives IOM/RWJF Report Advancing Health Care Informatics Nurse Standards by ANA CNE for Practicing Nurses Educational Content Dissemination Awareness Campaign Nursing HIT Curriculum Development HIT Orgs. For 400,000 Texas Nurses Nursing Leaders T.I.G.E.R Phase III Partnership Advisory Committee: Practice, Administration, Education and Vendors/Suppliers

17 HIT Committee Membership Composed of TNA and TONE Member from practice and academia Task Force Members Julie Brixey Nancy Crider (co-chair) Mary Anne Hanley Linda Harrington Susan McBride (PI) Elizabeth Sjoberg Laura Thomas Mari Tietze (co-chair) TNA Cindy Zolnierek [pres./co-pi] Laura Lerma [educ.] Kat Hinson [comm.] Amy Loewe [admin.] 1 7

18 Background Clinical Information Systems Implementation Evaluation Scale (CISIES) Survey* 1. Launched September 23, 2014, statewide 2. Over sampled rural hospitals in an effort to insure representation 3. Over 1,000 responses received Included a newly-developed** EHR maturity-index * = Gugerty, B. ** = McBride, S. & Tietze, M. 1 8

19 The goal: Develop a tool kit focused on evidence-based improvement using study findings to inform improvements Content for toolkit Use CISIES survey responses to guide toolkit content and focus groups to determine best strategies involving stakeholders Create and place on TNA and TONE Web sites Three CNE Webinars are being proposed based on immediate results: Workflow versus Work-Arounds to Optimize EHR Patient Safety and Quality. Interoperability of Electronic Health Records. Best Practices for Using EHRs in Nursing Practice within Interprofessional Teams 1 9

20 Policy/Legislation Implications Renew the 2010 TNA-TONE resolutions and add the following content: 1. Interoperability 2. Meaningful Use of EHRs (for Nursing) 3. Interprofessional Education/Collaboration 4. TIGER competencies initiative 5. Defining Best Practices for Using an EHR within the Clinical Workflow 2 0

21 Research Questions What are key issues with the current deployment of the electronic health record in the practice setting? What is the relationship between health setting characteristics and the nurses perceptions of their CIS? What is the relationship between the nurses characteristics and the nurses perceptions of their CIS? What is the relationship between CIS characteristics and the nurses perceptions of their CIS? What are the related core HIT competencies that should be covered in nursing education? 2 1

22 Research Design A descriptive and exploratory research study of the current nursing workforce in Texas, using a previously validated survey instrument, was conducted in select acute care facilities and their associated acute care, ambulatory/episodic care and long term care (LTC) units (Texas Workforce Center), collectively Health Care Organization to answer the research questions. (a priori power analysis/n=1,000) 2 2

23 First page of the TNA/TONE state wide online survey 23

24 Demographic information about EHR functionality (5 of 24 items) Meaningful Use Maturity-Sensitive Index for Nursing* (*McBride & Tietze, 2015) 2 4

25 Clinical Information System Implementation Evaluation Scale (CISIES) 2 5

26 Response Trend and Demographics

27 Study Responses Sept 2014-Feb 2015 Total N=1,177 TNA-TONE Push #2 TNA-TONE Push #1 2 7

28 Rural and Urban Represented Rural respondents were 52.7% acute care & 10.2% ambulatory Urban respondents were 52.7% acute care & 11.5% ambulatory 28

29 Meaningful Use Maturity-Sensitive Index for Nursing (MUMSI)*: Covariate Controlling for Maturity of the EHR *McBride, S. & Tietze, M. (2015)

30 Meaningful Use Maturity-Sensitive Index for Nursing Sample of 3 of the 24 Item scale aligned with Meaningful Use Stage 1 Measures Cronbach s Alpha Mean of (SD 13.85) Range 0-72 Content Validity using Lynn s method Lynn, M.R. Determination and Quantification of Content Validity. Nursing Research Vol. 35 No. 6 (1986) 3 0

31 Clinical Information System Implementation Evaluation Scale (Gugerty, B.)

32 CISIES 37 Survey Questions Cronbach s Alpha % Strongly agree or Agree That the system is more efficient than the old way of doing things 16.2% disagree or strongly disagree 3 2

33 Positive, Neutral and Negative Satisfaction are Equally Distributed Positive Neutral Negative 3 3

34 CISIES Distribution: How satisfied are nurses in Texas with EHRs? Differences in Satisfaction with EHRs related to MU maturity. < 0.5 CISIES Indicates Dissatisfaction Indicates Neutral or Not Completely Satisfied The MUMSI was calculated for all respondents based on 24 questions related to MU. The index score mean =56.53, median=59, range 0-72 (highest score possible). 2-5 Indicates Satisfied Gugerty, B., Maranda, M., Rook, D. (2006). The Clinical Information System Implementations Evaluation Scale, pp In H. A. Parks, P. Murray, & C. Delaney (Eds.) Consumer-centered computer-supported care for healthy people. Landsdale, PA: IOS Press. 3 4

35 Overall satisfaction with your CIS/EHR? 66% higher odds of being satisfied if urban (OR 1.65, 95% CI 1.145,2.401) 3 5

36 Overall satisfaction with your CIS/EHR? Region 36

37 Overall satisfaction with your CIS/EHR? Magnet Status 3 7

38 Overall satisfaction with your CIS/EHR? Position 38

39 Overall satisfaction with your CIS/EHR? 50% Direct Patient Care? 39

40 Overall Satisfaction and Nurses Age: Older nurses compared to younger nurses are less likely to be satisfied Age Controlling for MU maturity, nurses years are 36% (OR.431, 95% CI.227,.817, p=.01) less likely to be satisfied and nurses greater than 61 years are 68% less likely to be satisfied (OR.321, 95% CI.149,.690, p=.004) 40

41 Overall Satisfaction and Years in Nursing Nursing Practice Years Nurses in practice for < 5 years compared to all other groups: nurses in practice for 6-10 years are 78% more likely to be satisfied with their EHRs, while other groups were not significantly different with respect to satisfaction (OR 1.783; 95% CI 1.088, 2.923, p=.022). 41

42 Overall satisfaction with your CIS/EHR? EHR System Vendors Once the maturity of the EHR is taken into account there is no significant difference in any of the EHRs reported. 4 2

43 Varimax Rotation CISIES & EHR Path Diagram: Measuring 3 Distinct areas MUMSI Nurses are 2.8 X more likely to be satisfied when drug-drug and allergy alerts are not present (OR 2.815, 95% CI 1.591, p<.001) When alerts are present for clinical decisions and standards nurses are 2.76 X more likely to be satisfied compared to nurses who indicate the functionality is not present (OR 2.758, 95% CI 1.666, 4.566) CDS Associated with dissatisfaction CISIES 43

44 Qualitative Survey Data Themes Theme Word Count Percentage Frequency Electronic Medical Record % Charting % Nurses % Information % Computer System % Software % Patient % Care % Time % Health % Questions % Healthcare % Drugs % Physicians % Source:. NVIVO Word frequency distribution (Gilder, R. McBride, S. and Tietze, M., 2015) 44

45 Thematic Content Analysis Most effective in identifying concepts and themes Focus groups conducted to examine text themes Further detailed analysis with four examiners examined detailed text to reach consensus on subcategories 45

46 Narrative Themes Regarding Nurse Experiences with CIS/EHR Major and Minor Themes System design/usability Interoperability Patient safety and quality Documentation/legality Time Ns-pt time reduced/inefficiency Support IT, administrative, competency Workflow Med admin, work-arounds Distress Aggravation, voice not heard Communication Reduced consultation among clinicians 46

47 Evidence-Based Approach: Relationship Between Survey Factors and Potential Action Items Theme Potential Action Items/Interventions System design/usability Patient safety and quality/legality Utilize satisfied characteristics to improve dissatisfied & utilize dissatisfied characteristics to inform improvement strategy Integrate with relationship to design/usability Time: away from patient care Focus groups exploring clinician-based solutions delivery Time: inefficiency Focus groups exploring designer-based solutions (vendor and IT implementation) Support Assess/deploy needed resource support throughout organization Workflow Institute leadership-adopting a culture of improvement related to health IT Distress Provide collegial approach, interprofessional solutions and openly monitor progress Communication Emphasize open, consistent, throughout organization 47

48 Projected Timelines Analysis, Summarize Findings & Prepare Report Report to TNA/TONE Boards with recommendation on high level priorities based on the evidence Formulate Intervention Strategies based on the evidence Deploy Strategies Across Texas Target Follow-up Study to determine impact of interventions June-Aug 2015 Sept 2015 Oct-Dec 2015 Jan-Dec 2016 Oct-Dec

49 Contact Information Susan McBride, PhD, RN-BC, CPHIMS, FAAN Principle Investigator, Committee member Professor Texas Tech University Health Sciences Center Mari Tietze, PhD, RN-BC, FHIMSS Co-Chair and Co-investigator Associate Professor Texas Woman s University mtietze@twu.edu 49